Evaluating Abdominal Pain During Pregnancy

In Episode 60 of Med School Question of the Week for USMLE, Faustine Ramirez, MedSchoolCoach expert tutor, answers this medical school question: A 26-year-old primigravid woman at 34 weeks’ gestation presents to the emergency department with 6 hours of worsening, severe right flank pain, nausea, vomiting, malaise, and chills. She reports good fetal movement and mild intermittent uterine contractions. She denies vaginal bleeding or leakage of fluid. Temperature is 38.2 C, heart rate is 118/min, respiratory rate is 20/min, and blood pressure is 94/65. On examination she has diffuse abdominal tenderness, worse in the right mid-abdomen, without rebound, guarding, or costovertebral angle tenderness. Pelvic examination reveals a closed cervix. Laboratory studies reveal a serum leukocyte count of 17,400 with a left shift. Microscopic examination of a clean catch urine specimen shows 4-5 leukocytes and positive leukocyte esterase, and no nitrites or bacteria. Fetal heart tracing is reactive with moderate variability and a rate of 165/min. Which of the following is the most likely diagnosis?

• Cholecystitis
• Chorioamnionitis
• Pelvic inflammatory disease
• Pyelonephritis
• Appendicitis
• Hepatitis